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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 04/24/2024
Date Signed: 04/24/2024 05:52:05 PM


Document Has Been Signed on 04/24/2024 05:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:KENSINGTON AT WALNUT CREEK, THEFACILITY NUMBER:
079201241
ADMINISTRATOR:VILLANUEVA, JOSEPHFACILITY TYPE:
740
ADDRESS:1580 GEARY ROADTELEPHONE:
(925) 973-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:200CENSUS: 144DATE:
04/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Joseph Villanueva, Executive DirectorTIME COMPLETED:
06:10 PM
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On 04/24/2024 at 2:35 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 01/27/2024. LPA met with Executive Director, Joseph Villanueva, and explained the purpose of the visit.

LPA received an report of Suspected Elder Abuse that indicated allegations that the care staff witnessed one of the caregiver (S1) tell one of the residents (R1) "that if she fell that he would send her to the hospital and they will cut her leg off." S2 stated once they were notified by the care staff of the allegation that they started their own investigation. S2 stated that S1 was placed on paid administrative leave while pending investigation. S2 stated that S1 was terminated as a result of their investigation on 02/02/2024.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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